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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNERIOPERATOR I'� I/ �l /, ( / CHECK if BILLING ADDRESS <br /> FACILITY NAMEI�L"( <br /> SITE ADDRESS —/_- 7 j ( C�,V -12AL k�IE �2A- �s31 b <br /> Slreel Number Direction Street Name ,CIN Zi_Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number St eet Name _ <br /> CITY STATE ZIP <br /> Exr. APN# LAND USE APPLICATION# <br /> 2 bc?b�f <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> -- CONTRACTOR SERVICE REQUESTOR n <br /> rBUSINEss <br /> OR L /- �(t . I CHECK If BILLING ADDRESSO <br /> �Z. V PI�(a l� rT'L/ <br /> NAME 'Z ei O r �p,� r-/ PHglS_AILING ADDRESS /' �— V P L V FAX#/t; �n /C37 / STATE ZIP <br /> BILLING A KNOVVLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> 2U,vity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> �;OuNTY Ordinance Codes, Standards,STATE and FEDERAL law/s. <br /> I(� APPLICANT'S SIGNATURE: —124 'I//1/�/ Cf�� CATE: Z Z <br /> ` 1 PROPERTY/BUSINESS OWNER m OPERATOR I MANAGER ❑ OTHERAUTHORIZED AGENT ❑ <br /> \ If APPLICANT is not The BILLING PARTY proof of authorization to sign is required Title <br /> r AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release Of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time It Is provided t0 me Or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED: c5lrisyl on �C <br /> COMMENTS: 2� 1� o <br /> N IN Ery�gQUly <br /> hfq�TtiRn N M�A <br /> r <br /> ACCEPTED BY: EMPLOYEE#: Rr <br /> DAfE: a-06 / / <br /> ASSIGNED TO: EMPLOYEE#: DATE: Z- 2- <br /> f-Y) <br /> - `p <br /> I�I M <br /> Date Service Completed (if already completed): SERVICE CODE: Q PIE: i Q <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />